-
arterial line
placed at the wrist
No range of motion or weight-bearing activities
-
Swan Ganz (PA) catheter
a catheter that is placed over the chest
Must be very cautious when getting them out of bed
-
IABP
intra-aortic balloon pump
hip should not be flexed greater than 90°
-
PICC
peripherally inserted central catheter
Usually located at the elbow – don't take blood pressure over it
-
Foley catheter
catheter that is placed into the urethra and bladder
-
Hickman line
- is not used very often
- surgically implanted
- used to administer chemotherapy
-
mean blood pressure
- 70 – 10 mmHg is normal
- MBP=DBP+1/3(pulse pressure)
- If MAP drops below 60 don't get out of bed
-
thoracic deformities – COPD
ground, barrel chest, anterior chest lifted
-
Chest deformities – pectus excavatum
sternum posteriorly – potential compression on heart and lungs
-
Chest deformities – pectus incarinatum
sternum anterior, pigeon breast
-
what increases work of breathing
respiratory rate, accessory muscle use, decreased compliance, increase airway resistance, abnormal breathing patterns
-
-
hypernea
breathing deeper and faster
-
orthopnea
trouble breathing laying down
-
apnea
cessation a breathing
-
Cheyne stokes
increased depth, apnea = icp, chf
-
Kussmauls:
irregular rate and depth, ketoacidosis, renal failure
-
sputum
Clear
colorful
hemoptysis
- clear = normal
- colorful = infection
- hemoptysis = pulmonary embolism, cancer
-
sputum – Frothy/white
pulmonary edema
-
sputum – tenacious
cystic fibrosis
-
juvenile venous distention
- backing up of fluid in the venous system – usually right heart failure
- quotation into semi recumbent position of 45°, turned her head away
- normally 3-5 cm above sternum, more than that is abnormal
-
Patechiae
small purplish spots = average, thrombocytopenia
-
pitting edema scale
- 1+ = trace, barely a depression
- 2+ = mild, skin rebounds in <15 seconds
- 3+ = moderate, skin rebounds and 15 – 30 seconds
- 4+ = severe, skin rebounds in >30 seconds
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